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NTSB Report

June 28, 2024 · Cessna 182 · N6210A

Big Creek, ID

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
June 28, 2024
Injury Outcomes
2 injuries (1 fatality, 1 serious injury)
Location
Big Creek, ID
Aircraft
Cessna 182 (1956)
Tail Number
N6210A
Operator
Depot Avionics
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
WPR24FA215

On June 28, 2024, about 1728 mountain daylight time, a Cessna 182, N6210A was substantially damaged when it was involved in an accident near Big Creek, Idaho. The pilot was fatally injured, and the pilot-rated-passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a witness who spoke to the pilot, he and his son arrived at a fly in at Smiley Creek Airport (U87) Smiley Creek, Idaho, the day of the accident and planned to fly to the Big Creek Airport (U60) Big Creek, Idaho, for the evening. The witness recalled seeing the airplane depart U87 around 1630 to 1645. According to a witness, located inside the Big Creek Lodge, around 1727, he heard an airplane flying nearby and they looked outside to see it as it passed the lodge at a low altitude, and while in a nose high attitude. The witness stated that he stepped outside, heard the engine “making full power” but the airplane was “not doing anything significant.” He saw the left wing begin to drop and the airplane entered the trees and disappeared. Examination of the accident site revealed that the airplane impacted forested hilly terrain. The airplane came to rest on its right side, on a heading of about 270° magnetic, and at an elevation of 5,742 ft msl. The wreckage was surrounded by trees about 50 ft to 80 ft in height and was about 1,400 ft south of the departure end of runway 19. All major components of the airplane were located at the accident site. The wreckage was transported to a secure facility for further examination.

NTSB Probable Cause

The pilot’s delayed decision to go around after descending below the recommended abort altitude with a slight tailwind and an over-gross-weight airplane, which resulted in impact with trees and terrain. Contributing to the accident was the pilot’s failure to follow the published guidance for airport operations.

Full Narrative

HISTORY OF FLIGHTOn June 28, 2024, about 1730 mountain daylight time, a Cessna 182 airplane, N6210A, was substantially damaged when it was involved in an accident near Big Creek, Idaho. The pilot was fatally injured, and the pilot-rated passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot-rated passenger, he and his father departed Smiley Creek Airport (U87), Smiley Creek, Idaho, destined for Big Creek Airport (U60), Big Creek, Idaho. Before the departure a personal electronic video camera was installed under the left wing. EDM data revealed that during the departure the engine speed increased to 2700 rpm while about 7,200 ft mean sea level (msl) and about 30°C, and at a density altitude of about 10,200 ft. The pilot was seated in the left seat and the pilot-rated passenger was seated in the right seat. While enroute to U60, the pilot-rated passenger was flying the airplane and the pilot provided instruction on mountain flying techniques. ADS-B data showed the airplane maneuvering throughout the flight, consistent with the pilot-rated passenger’s statement of the pilot demonstrating mountain flying techniques. The pilot-rated passenger reported that the engine was running well. He relinquished the flight controls to the pilot when the airplane was about seven miles from U60. The pilot-rated passenger recalled that upon arrival at U60, the wind was tolerable and that the landing would be with a slight tailwind. ADS-B, onboard instruments, and recorded video from the onboard camera revealed that the airplane was established on the downwind leg, east of runway 19 about 7112 ft msl and about 71 knots groundspeed. The flaps were lowered to the first detent, and the engine sound reduced then subsequently raised before the base leg turn. The airplane turned to the base leg when it was about 1,700 ft beyond the runway threshold. While the airplane was near the mid-point of the base leg it was about 6596 ft msl and 76 knots. Engine power was reduced and the flaps were lowered further. Engine power was then reduced to near idle on the descent, where it remained for the rest of the descent. About the time that the airplane was over the approach end of runway it was about 6131 ft msl (or about 414 ft above ground level [agl]) and about 95 knots, in a nose-low attitude. The pilot-rated passenger estimated that their altitude was high and the airspeed was fast. He asked the pilot if they were going to go around. ADS-B data showed that the airplane’s ground speed continued to increase to a maximum of about 98 knots over the first 1/3 of the runway. The pilot-rated passenger recalled that the pilot attempted to slip the airplane aggressively but then decided to perform a go-around. The airplane reached its lowest point of the approach about 5731 ft msl, or about 10 to 30 ft agl, at a groundspeed of about 70 knots. At this point, the airplane had overflown about 3,000 ft of the runway. Within the next three seconds, engine power increased consistent with go-around power being applied, and the flaps were raised. EDM data showed that engine speed then increased to about 2,500 rpm at 20 inches of manifold pressure, while about 5,761 ft msl and about 15°C, and a density altitude of about 6,942 ft. During the go-around, the airplane passed a windsock that indicated a tailwind of about 3 knots. The airplane then passed the end of the runway about three seconds later at a speed of about 64 knots. The airplane maneuvered to the left over an area of lower obstructions. The on-board video camera showed the flaps move up slightly then lower to their previous position. The airplane then maneuvered to the right. The flaps were then lowered slightly before they raised to their full up position. The right wing impacted a tree followed by the fuselage. The pilot-rated passenger recalled that the pilot attempted to use the open areas to avoid the trees but was unsuccessful. The pilot then maneuvered the airplane so that the wing impacted the trees and not “head on.” The pilot-rated passenger reported that the event was not a stall/spin, rather a controlled flight into terrain given the airplane could not outclimb the rising terrain. The last GPS data point captured the airplane about 57 knots groundspeed and about 330 ft northwest of the accident site. Figure 1. Idaho Division of Aeronautics (IDA) illustration on left shows the recommended traffic pattern for U60. The Google Earth image on the right shows the flight pattern of the pilot in white and the IDA recommended base-to-final turn location. A witness, located inside a lodge near the landing strip, reported hearing an airplane under power. He looked out of the window and saw the airplane flying “uphill.” He walked outside and saw the airplane not climbing but moving toward the trees. He saw the left wing drop just before the airplane disappeared into the trees and he was able to capture a photograph it did. The photograph shows that the flaps appeared to be extended (see figure 2). Figure 2. Photo of the airplane flying over the open field southeast of the runway's end and toward rising terrain. The enlarged box shows the flaps extended at that time. PERSONNEL INFORMATIONThe pilot’s flight logs were not available for review; his flight experience was estimated by a family member. According to the pilot-rated passenger, on the day of the accident the pilot’s skills and decision making were fully intact. AIRCRAFT INFORMATIONAccording to the engine datasheet, the NorthPoint XP470 engine’s approximate power settings were: Full manifold pressure 28 inches + 2700 rpm = 100% power 24 inches + 2400 rpm = 75% power 23 inches + 2300 rpm = 65% power 22 inches + 2200 rpm = 56% power The maximum engine speed was 2700 rpm (red line); the engine’s yellow arc was 1850 to 2150 rpm and the green arc was 2200 to 2600 rpm . A review of the EDM data revealed that, about the time of the go-around, the engine was producing about 2,550 rpm, at 20 inches of manifold pressure, and about 68% of maximum horsepower. The airplane’s weight and balance were calculated with the following data. Pilot and pilot-rated passenger’s combined weight of 550 pounds, fuel weight of 240 pounds [40 gallons], baggage weight of 200 pounds, and an empty airplane weight of 1,720.53 pounds. The gross weight totaled 2,710.53 pounds. According to the owner’s manual, the maximum gross weight was 2,550 pounds. The center of gravity calculation was outside the envelope of the performance chart. The owner’s manual did not detail go-arounds, but stated in part, For maximum climb performance use full throttle and 2600 RPM. The sea level best rate of climb speed is 89 MPH, IAS at sea level, and is reduced ½ MPH for every 1,000 feet of altitude above sea level. If an obstruction dictates using a steep climb angle, the best angle-of-climb speed should be used with wing flaps up, full throttle and 2,600 RPM. The best angle-of-climb speed is 70 MPH, IAS. If ten (10) degrees wing flaps are used for take-offs, they should be left on until all obstacles are cleared. To clear an obstacle with wing flaps 10 degrees, the best angle-of-climb speed (60 MPH, IAS) should be used…These speeds vary slightly with altitude, but they are close enough for average field elevations. Take-Off. 1. Normal Take-Off – Normal take-offs are accomplished with wing flaps up, full throttle, and 2600 RPM. Reduce power to 23 inches manifold pressure and 2450 RPM as soon as practical to minimize engine wear. 2. Use of Flaps for Take-Off – The take-off ground run with wing flaps 10 degrees is approximately 25% less than the take-off run with the flaps retracted. The use of 10 degrees wing flaps reduces the total distance over a 50-foot obstacle by approximately 20%. This is a result of slower forward speeds even though the use of wing flaps lessons the rate of climb. Therefore, for increased take-off performance, the recommended technique is to lower wing flaps 10 degrees (first notch)…30 and 40 degree wing flaps are not recommended at any time for take-off. AIRPORT INFORMATIONAccording to the engine datasheet, the NorthPoint XP470 engine’s approximate power settings were: Full manifold pressure 28 inches + 2700 rpm = 100% power 24 inches + 2400 rpm = 75% power 23 inches + 2300 rpm = 65% power 22 inches + 2200 rpm = 56% power The maximum engine speed was 2700 rpm (red line); the engine’s yellow arc was 1850 to 2150 rpm and the green arc was 2200 to 2600 rpm . A review of the EDM data revealed that, about the time of the go-around, the engine was producing about 2,550 rpm, at 20 inches of manifold pressure, and about 68% of maximum horsepower. The airplane’s weight and balance were calculated with the following data. Pilot and pilot-rated passenger’s combined weight of 550 pounds, fuel weight of 240 pounds [40 gallons], baggage weight of 200 pounds, and an empty airplane weight of 1,720.53 pounds. The gross weight totaled 2,710.53 pounds. According to the owner’s manual, the maximum gross weight was 2,550 pounds. The center of gravity calculation was outside the envelope of the performance chart. The owner’s manual did not detail go-arounds, but stated in part, For maximum climb performance use full throttle and 2600 RPM. The sea level best rate of climb speed is 89 MPH, IAS at sea level, and is reduced ½ MPH for every 1,000 feet of altitude above sea level. If an obstruction dictates using a steep climb angle, the best angle-of-climb speed should be used with wing flaps up, full throttle and 2,600 RPM. The best angle-of-climb speed is 70 MPH, IAS. If ten (10) degrees wing flaps are used for take-offs, they should be left on until all obstacles are cleared. To clear an obstacle with wing flaps 10 degrees, the best angle-of-climb speed (60 MPH, IAS) should be used…These speeds vary slightly with altitude, but they are close enough for average field elevations. Take-Off. 1. Normal Take-Off – Normal take-offs are accomplished with wing flaps up, full throttle, and 2600 RPM. Reduce power to 23 inches manifold pressure and 2450 RPM as soon as practical to minimize engine wear. 2. Use of Flaps for Take-Off – The take-off ground run with wing flaps 10 degrees is approximately 25% less than the take-off run with the flaps retracted. The use of 10 degrees wing flaps reduces the total distance over a 50-foot obstacle by approximately 20%. This is a result of slower forward speeds even though the use of wing flaps lessons the rate of climb. Therefore, for increased take-off performance, the recommended technique is to lower wing flaps 10 degrees (first notch)…30 and 40 degree wing flaps are not recommended at any time for take-off. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site revealed that the airplane impacted forested mountainous terrain. The airplane came to rest on its right side, on a heading of about 270° magnetic and at an elevation of 5,742 ft msl. The terrain increased in elevation significantly to the southwest. The wreckage was surrounded by trees about 50 to 80 ft in height and was about 1,400 ft south of the departure end of runway 19. All major components of the airplane were located at the accident site. Some camping gear was stacked outside of the airplane. Postaccident examination of the airplane revealed no mechanical malfunctions or failures that would have precluded normal operation. Flight control continuity was established from the flight controls to the flight control surfaces. Engine performance was confirmed via an engine data monitor that revealed the engine was operating normally before the accident. ADDITIONAL INFORMATIONThe FAA Airplane Flying Handbook (FAA-H-8083-3C) stated, in part: For maximum takeoff power, the propeller control is moved all the way forward to the low pitch/high rpm position, and the throttle is moved forward to the maximum allowable manifold pressure position. To reduce power for climb or cruise ,manifold pressure is reduced to the desired value with the throttle, and the engine rpm is reduced by moving the propeller control back toward the high pitch/low rpm position until the desired rpm is observed on the tachometer. Pulling back on the propeller control causes the propeller blades to move to a higher angle. Increasing the propeller blade angle (of attack) results in an increase in the resistance of the air. This puts a load on the engine so it slows down. MEDICAL AND PATHOLOGICAL INFORMATIONThe pilot’s autopsy was performed at the Ada County Coroner’s Office, Meridian, Idaho, as authorized by the Valley County Coroner’s Office, McCall, Idaho. According to the autopsy report, the pilot's cause of death was multiple blunt force injuries. Postmortem toxicological testing of the pilot by the FAA Forensic Sciences Laboratory detected cyclobenzaprine at 2 ng/mL in femoral blood and at 1 ng/mL in urine. Norcyclobenzaprine was detected at 3 ng/mL in femoral blood and at 2 ng/mL in urine. Cetirizine was detected at 44 ng/mL in femoral blood and at 946 ng/mL in urine. Diphenhydramine was detected in femoral blood at a level below the lower limit of quantitation. Diphenhydramine was also detected in urine. Lisinopril, metoprolol, and acetaminophen were also detected in femoral blood and urine. Cyclobenzaprine and metabolite – Cyclobenzaprine is a prescription medication that acts on the central nervous system to produce muscle-relaxing effects for relief of musculoskeletal pain. Norcyclobenzaprine is an active metabolite of cyclobenzaprine. Cyclobenzaprine commonly causes drowsiness and often carries a warning that it may impair mental and/or physical abilities required for performance of hazardous tasks, such as operating machinery or driving a motor vehicle. Specific effects depend on variables including tolerance, dosage, and formulation. The FAA considers cyclobenzaprine to be a “Do Not Fly” medication. According to the FAA medical case review for this accident, cyclobenzaprine use is conditionally acceptable for pilots if used for a single episode for a time-limited condition, subject to an 8-day waiting period after the last dose before flying. In living people, the typical therapeutic concentration of cyclobenzaprine in plasma is about 3 ng/mL to 40 ng/mL, with an uncertain blood-to-plasma concentration ratio and a typical elimination half-life of about 9-40 hours. Cetirizine – Cetirizine is a second-generation antihistamine medication that is available over the counter and commonly is used to treat allergy symptoms. Cetirizine often carries a warning that users may experience drowsiness and should be careful when driving a motor vehicle or operating machinery. Data on sedation and psychomotor impairment from cetirizine are mixed, with some studies finding some sedating and impairing effects. As such, cetirizine generally is understood to be more likely to cause significant sedation than other common second-generation antihistamines (such as loratadine or fexofenadine) and less likely to cause significant sedation than common first-generation antihistamines (such as diphenhydramine). Cetirizine is on the FAA’s list of “no go” over-the-counter medications for pilots, which instructs pilots to observe a waiting period after use before flying, to provide sufficient time for the drug to be cleared from circulation. The FAA Guide for Aviation Medical Examiners indicates that otherwise-qualified applicants may be issued pilot medical certification if using cetirizine occasionally (one to two times per week, not daily), but that they should wait 48 hours after using the drug before flying. Diphenhydramine – Diphenhydramine is a sedating antihistamine medication widely available over the counter in multiple sleep aids and cold and allergy products. Diphenhydramine can cause cognitive and psychomotor slowing and drowsiness, and often carries a warning about driving and operating machinery. FAA guidance indicates that pilots should not fly within 60 hours of using diphenhydramine, to allow time for it to be cleared from circulation. Other medications – Lisinopril is a prescription medication commonly used to treat high blood pressure. Metoprolol is a prescription medication that can be used as part of treatment for high blood pressure, certain arrhythmias, and certain types of heart failure. Acetaminophen is a medication widely available in a variety of over-the- counter products for treating pain and fever. Lisinopril, metoprolol, and acetaminophen are not typically impairing.

Flight

Event TypeAccident
Event Time17:28 MDT
Nearest AirportBig Creek Airport (3230nm SSW)
Runway19
Runway Length3550 ft
Runway Width110 ft
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna 182
Tail NumberN6210A
Aircraft CategoryAir
DamageSubstantial
OperatorDepot Avionics
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsNorthpoint · XP-470 · Reciprocating
Seats4

People & Injuries

Injury Summary2 injuries (1 fatality, 1 serious injury)
Fatal1
Serious1
Minor0
Uninjured0
Total2
Crew 1Age 36 · None · Serious
Crew 2Age 63 · Basc · Fatal

Conditions

ConditionsVMC
LightDaylight
WindCalm
Visibility10 sm
CeilingNone
Temperature / Dew Point70 F / 36 F
Altimeter30.02 inHg
Observation Time16:51
Weather SourceWFAC

Appendix: Source Data